Download CHAPTER e24 Infectious Complications of Bites - McGraw

C H AP T E R e2 4
Infectious Complications
of Bites
Lawrence C. Madoff
Florencia Pereyra
䡵 DOG BITES
In the United States, dogs bite >4.7 million people each year and
are responsible for 80% of all animal-bite wounds, an estimated
15–20% of which become infected. Each year, 800,000 Americans
seek medical attention for dog bites; of those injured, 386,000
require treatment in an emergency department, with >1000 emergency department visits each day and about a dozen deaths per year.
Most dog bites are provoked and are inflicted by the victim’s pet or
by a dog known to the victim. These bites frequently occur during
efforts to break up a dogfight. Children are more likely than adults
to sustain canine bites, with the highest incidence of 6 bites per
1000 population among boys 5–9 years old. Victims are more often
male than female, and bites most often involve an upper extremity. Among children <4 years old, two-thirds of all these injuries
involve the head or neck. Infection typically manifests 8–24 h after
the bite as pain at the site of injury with cellulitis accompanied by
purulent, sometimes foul-smelling discharge. Septic arthritis and
osteomyelitis may develop if a canine tooth penetrates synovium
or bone. Systemic manifestations (e.g., fever, lymphadenopathy,
and lymphangitis) may also occur. The microbiology of dog-bite
wound infections is usually mixed and includes β-hemolytic
streptococci, Pasteurella species, Staphylococcus species [including
methicillin-resistant Staphylococcus aureus (MRSA)], Eikenella
corrodens, and Capnocytophaga canimorsus. Many wounds also
include anaerobic bacteria such as Actinomyces, Fusobacterium,
Prevotella, and Porphyromonas species.
While most infections resulting from dog-bite injuries are localized to the area of injury, many of the microorganisms involved
are capable of causing systemic infection, including bacteremia,
䡵 CAT BITES
Although less common than dog bites, cat bites and scratches result
in infection in more than half of all cases. Because the cat’s narrow,
sharp canine teeth penetrate deeply into tissue, cat bites are more
likely than dog bites to cause septic arthritis and osteomyelitis; the
development of these conditions is particularly likely when punctures are located over or near a joint, especially in the hand. Women
sustain cat bites more frequently than do men. These bites most
often involve the hands and arms. Both bites and scratches from
cats are prone to infection from organisms in the cat’s oropharynx.
Pasteurella multocida, a normal component of the feline oral flora,
is a small gram-negative coccobacillus implicated in the majority of
cat-bite wound infections. Like that of dog-bite wound infections,
however, the microflora of cat-bite wound infections is usually
mixed. Other microorganisms causing infection after cat bites are
similar to those causing dog-bite wound infections.
The same risk factors for systemic infection following dog-bite
wounds apply to cat-bite wounds. Pasteurella infections tend to
advance rapidly, often within hours, causing severe inflammation accompanied by purulent drainage; Pasteurella may also be
spread by respiratory droplets from animals, resulting in pneumonia or bacteremia. Like dog-bite wounds, cat-bite wounds
may result in the transmission of rabies or in the development
of tetanus. Infection with Bartonella henselae causes cat-scratch
disease (Chap. 160) and is an important late consequence of cat
bites and scratches. Tularemia (Chap. 158) has also been reported
to follow cat bites.
CHAPTER e24 Infectious Complications of Bites
The skin is an essential component of the nonspecific immune
system, protecting the host from potential pathogens in the environment. Breaches in this protective barrier thus represent a form
of immunocompromise that predisposes the patient to infection.
Bites and scratches from animals and humans allow the inoculation
of microorganisms past the skin’s protective barrier into deeper,
susceptible host tissues.
Each year in the United States, millions of animal-bite wounds
are sustained. The vast majority are inflicted by pet dogs and cats,
which number >100 million; the annual incidence of dog and cat
bites has been reported as 300 bites per 100,000 population. Other
bite wounds are a consequence of encounters with animals in the
wild or in occupational settings. While many of these wounds
require minimal or no therapy, a significant number result in
infection, which may be life-threatening. The microbiology of bitewound infections in general reflects the oropharyngeal flora of the
biting animal, although organisms from the soil, the skin of the
animal and victim, and the animal’s feces may also be involved.
meningitis, brain abscess, endocarditis, and chorioamnionitis.
These infections are particularly likely in hosts with edema or compromised lymphatic drainage in the involved extremity (e.g., after
a bite on the arm in a woman who has undergone mastectomy)
and in patients who are immunocompromised by medication or
disease (e.g., glucocorticoid use, systemic lupus erythematosus,
acute leukemia, or hepatic cirrhosis). In addition, dog bites and
scratches may result in systemic illnesses such as rabies (Chap. 195)
and tetanus (Chap. 140).
Infection with C. canimorsus following dog-bite wounds may
result in fulminant sepsis, disseminated intravascular coagulation, and renal failure, particularly in hosts who have impaired
hepatic function, who have undergone splenectomy, or who are
immunosuppressed. This organism is a thin gram-negative rod that
is difficult to culture on most solid media but grows in a variety of
liquid media. The bacteria are occasionally seen within polymorphonuclear leukocytes on Wright-stained smears of peripheral blood
from septic patients. Tularemia (Chap. 158) has also been reported
to follow dog bites.
䡵 OTHER ANIMAL BITES
Infections have been attributed to bites from many animal species.
Often these bites are sustained as a consequence of occupational
exposure (farmers, laboratory workers, veterinarians) or recreational exposure (hunters and trappers, wilderness campers, owners
of exotic pets). Generally, the microflora of bite wounds reflects
the oral flora of the biting animal. Most members of the cat family,
including feral cats, harbor P. multocida. Bite wounds from aquatic
animals such as alligators or piranhas may contain Aeromonas
hydrophila. Venomous snakebites (Chap. 396) result in severe
inflammatory responses and tissue necrosis—conditions that render
these injuries prone to infection. The snake’s oral flora includes many
species of aerobes and anaerobes, such as Pseudomonas aeruginosa,
Copyright © 2012 The McGraw-Hill Companies, Inc. All rights reserved.
24-1
PART 8
Infectious Diseases
Proteus species, Staphylococcus epidermidis, Bacteroides fragilis, and
Clostridium species. Bites from nonhuman primates are highly susceptible to infection with pathogens similar to those isolated from
human bites (see below). Bites from Old World monkeys (Macaca)
may also result in the transmission of B virus (Herpesvirus simiae,
cercopithecine herpesvirus), a cause of serious infection of the
human central nervous system. Bites of seals, walruses, and polar
bears may cause a chronic suppurative infection known as seal
finger, which is probably due to one or more species of Mycoplasma
colonizing these animals.
Small rodents, including rats, mice, and gerbils, as well as
animals that prey on rodents may transmit Streptobacillus
moniliformis (a microaerophilic, pleomorphic gramnegative rod) or Spirillum minor (a spirochete), which cause a
clinical illness known as rat-bite fever. The vast majority of cases in
the United States are streptobacillary, whereas Spirillum infection
occurs mainly in Asia.
In the United States, the risk of rodent bites is usually greatest
among laboratory workers or inhabitants of rodent-infested
dwellings (particularly children). Rat-bite fever is distinguished
from acute bite-wound infection by its typical manifestation after
the initial wound has healed. Streptobacillary disease follows an
incubation period of 3–10 days. Fever, chills, myalgias, headache, and severe migratory arthralgias are usually followed by a
maculopapular rash, which characteristically involves the palms
and soles and may become confluent or purpuric. Complications
include endocarditis, myocarditis, meningitis, pneumonia, and
abscesses in many organs. Haverhill fever is an S. moniliformis
infection acquired from contaminated milk or drinking water
and has similar manifestations. Streptobacillary rat-bite fever
was frequently fatal in the preantibiotic era. The differential
diagnosis includes Rocky Mountain spotted fever, Lyme disease,
leptospirosis, and secondary syphilis. The diagnosis is made by
direct observation of the causative organisms in tissue or blood,
by culture of the organisms on enriched media, or by serologic
testing with specific agglutinins.
Spirillum infection (referred to in Japan as sodoku) causes pain
and purple swelling at the site of the initial bite, with associated
lymphangitis and regional lymphadenopathy, after an incubation
period of 1–4 weeks. The systemic illness includes fever, chills, and
headache. The original lesion may eventually progress to an eschar.
The infection is diagnosed by direct visualization of the spirochetes
in blood or tissue or by animal inoculation.
Finally, NO-1 (CDC nonoxidizer group 1) is a bacterium associated with dog- and cat-bite wounds. Infections in which NO-1 has
been isolated have tended to manifest locally (i.e., as abscess and
cellulitis). These infections have occurred in healthy persons with
no underlying illness and in some instances have progressed from
localized to systemic illnesses. The phenotypic characteristics of
NO-1 are similar to those of asaccharolytic Acinetobacter species;
i.e., NO-1 is oxidase-, indole-, and urease-negative. To date, all
strains identified have been shown to be susceptible to aminoglycosides, β-lactam antibiotics, tetracyclines, quinolones, and
sulfonamides.
䡵 HUMAN BITES
Human bites may be self-inflicted; may be sustained by medical personnel caring for patients; or may take place during fights, domestic
abuse, or sexual activity. Human-bite wounds become infected
more frequently (∼10–15% of the time) than do bites inflicted by
other animals. These infections reflect the diverse oral microflora of
humans, which includes multiple species of aerobic and anaerobic
bacteria. Common aerobic isolates include viridans streptococci,
24-2
S. aureus, E. corrodens (which is particularly common in clenched-fist
injury; see below), and Haemophilus influenzae. Anaerobic species,
including Fusobacterium nucleatum and Prevotella, Porphyromonas,
and Peptostreptococcus species, are isolated from 50% of human-bite
wound infections; many of these isolates produce β-lactamases.
The oral flora of hospitalized and debilitated patients often includes
Enterobacteriaceae in addition to the usual organisms. Hepatitis B,
hepatitis C, herpes simplex virus infection, syphilis, tuberculosis,
actinomycosis, and tetanus have been reported to be transmitted
by human bites; it is biologically possible to transmit HIV through
human bites, although this event is quite unlikely.
Human bites are categorized as either “occlusional” injuries,
which are inflicted by actual biting, or “clenched-fist” injuries,
which are sustained when the fist of one individual strikes the teeth
of another, causing traumatic laceration of the hand. For several
reasons, clenched-fist injuries, which are more common than
occlusional injuries, result in particularly serious infections. The
deep spaces of the hand, including the bones, joints, and tendons,
are frequently inoculated with organisms in the course of such
injuries. The clenched position of the fist during injury, followed
by extension of the hand, may further promote the introduction of
bacteria as contaminated tendons retract beneath the skin’s surface.
Moreover, medical attention is often sought only after frank infection develops.
APPROACH TO THE
PATIENT
Animal or Human Bites
A careful history should be elicited, including the type of biting
animal, the type of attack (provoked or unprovoked), and the
amount of time elapsed since injury. Local and regional publichealth authorities should be contacted to determine whether an
individual species could be rabid and/or to locate and observe
the biting animal when rabies prophylaxis may be indicated
(Chap. 195). Suspicious human-bite wounds should provoke
careful questioning regarding domestic or child abuse. Details
on antibiotic allergies, immunosuppression, splenectomy, liver
disease, mastectomy, and immunization history should be
obtained. The wound should be inspected carefully for evidence
of infection, including redness, exudate, and foul odor. The
type of wound (puncture, laceration, or scratch); the depth of
penetration; and the possible involvement of joints, tendons,
nerves, and bones should be assessed. It is often useful to include
a diagram or photograph of the wound in the medical record. In
addition, a general physical examination should be conducted
and should include an assessment of vital signs as well as an
evaluation for evidence of lymphangitis, lymphadenopathy,
dermatologic lesions, and functional limitations. Injuries to the
hand warrant consultation with a hand surgeon for the assessment of tendon, nerve, and muscular damage. Radiographs
should be obtained when bone may have been penetrated or a
tooth fragment may be present. Culture and Gram’s staining
of all infected wounds are essential; anaerobic cultures should
be undertaken if abscesses, devitalized tissue, or foul-smelling
exudate is present. A small-tipped swab may be used to culture
deep punctures or small lacerations. It is also reasonable to
culture samples from uninfected wounds due to bites inflicted
by animals other than dogs and cats, since the microorganisms
causing disease are less predictable in these cases. The white
blood cell count should be determined and blood cultured if
systemic infection is suspected.
Copyright © 2012 The McGraw-Hill Companies, Inc. All rights reserved.
TREATMENT
Bite-Wound Infections
WOUND MANAGEMENT Wound closure is controversial in bite
injuries. Many authorities prefer not to attempt primary closure
of wounds that are or may become infected, preferring to irrigate these wounds copiously, debride devitalized tissue, remove
foreign bodies, and approximate the wound edges. Delayed
primary closure may be undertaken after the risk of infection
is over. Small uninfected wounds may be allowed to close by
secondary intention. Puncture wounds due to cat bites should
be left unsutured because of the high rate at which they become
infected. Facial wounds are usually sutured after thorough
cleaning and irrigation because of the importance of a good
cosmetic result in this area and because anatomic factors such as
an excellent blood supply and the absence of dependent edema
lessen the risk of infection.
ANTIBIOTIC THERAPY
Established Infection Antibiotics should be administered in all
established bite-wound infections and should be chosen in light
of the most likely potential pathogens, as indicated by the biting
species and by Gram’s stain and culture results (Table e24-1).
For dog and cat bites, antibiotics should be effective against
S. aureus, Pasteurella species, C. canimorsus, streptococci, and
oral anaerobes. For human bites, agents with activity against
S. aureus, H. influenzae, and β-lactamase-positive oral anaerobes
should be used. The combination of an extended-spectrum
penicillin with a β-lactamase inhibitor (amoxicillin/clavulanic
acid, ticarcillin/clavulanic acid, ampicillin/sulbactam) appears
to offer the most reliable coverage for these pathogens. Secondgeneration cephalosporins (cefuroxime, cefoxitin) also offer
substantial coverage. The choice of antibiotics for penicillinallergic patients (particularly those in whom immediate-type
hypersensitivity makes the use of cephalosporins hazardous) is
more difficult and is based primarily on in vitro sensitivity since
data on clinical efficacy are inadequate. The combination of an
antibiotic active against gram-positive cocci and anaerobes (such
as clindamycin) with trimethoprim-sulfamethoxazole or a fluoroquinolone, which is active against many of the other potential
pathogens, would appear reasonable. In vitro data suggest that
TABLE e24-1 Management of Wound Infections Following Animal and Human Bites
Commonly Isolated
Pathogens
Preferred
Antibiotic(s) a
Alternative in
Penicillin-Allergic Patient
Dog
Staphylococcus aureus,
Pasteurella multocida,
anaerobes, Capnocytophaga
canimorsus
Amoxicillin/clavulanate
(250–500 mg PO tid)
or ampicillin/sulbactam (1.5–3.0 g IV q6h)
Clindamycin (150–300 mg
PO qid) plus either
TMP-SMX (1 DS tablet PO
bid) or ciprofloxacin
(500 mg PO bid)
Cat
P. multocida, S. aureus,
anaerobes
Human,
occlusional
Viridans streptococci,
S. aureus, Haemophilus
influenzae, anaerobes
Other
Considerations
Sometimes b
Consider rabies
prophylaxis.
Amoxicillin/clavulanate Clindamycin plus
or ampicillin/
TMP-SMX as above or a
sulbactam as above
fluoroquinolone
Usually
Consider rabies
prophylaxis.
Carefully evaluate
for joint/bone
penetration.
Amoxicillin/clavulanate Erythromycin (500 mg PO
or ampicillin/
qid) or a fluoroquinolone
sulbactam as above
Always
Examine for
tendon, nerve, or
joint involvement.
Human,
As for occlusional plus
clenched-fist Eikenella corrodens
Ampicillin/sulbactam
as above or imipenem
(500 mg q6h)
Cefoxitin c
Always
Examine for tendon, nerve, or joint
involvement.
Monkey
As for human bite
As for human bite
As for human bite
Always
For macaque
monkeys, consider
B virus prophylaxis
with acyclovir.
Snake
Pseudomonas aeruginosa,
Proteus spp., Bacteroides
fragilis, Clostridium spp.
Ampicillin/sulbactam
as above
Clindamycin plus TMP-SMX Sometimes, especially Antivenin for
as above or a
with venomous snakes venomous snake
fluoroquinolone
bite
Rodent
Streptobacillus moniliformis, Penicillin VK (500 mg
Leptospira spp.,
PO qid)
P. multocida
Doxycycline (100 mg
PO bid)
Sometimes
CHAPTER e24 Infectious Complications of Bites
Biting
Species
Prophylaxis
Advised for Early
Uninfected
Wounds
—
a
Antibiotic choices should be based on culture data when available. These suggestions for empirical therapy need to be tailored to individual circumstances and local conditions. IV regimens should be used for hospitalized patients. A single IV dose of antibiotics may be given to patients who will be discharged after initial management.
b
Prophylactic antibiotics are suggested for severe or extensive wounds, facial wounds, and crush injuries; when bone or joint may be involved; and when comorbidity is present
(see text).
c
May be hazardous in patients with immediate-type hypersensitivity reaction to penicillin.
Abbreviations: DS, double-strength; TMP-SMX, trimethoprim-sulfamethoxazole.
Copyright © 2012 The McGraw-Hill Companies, Inc. All rights reserved.
24-3
PART 8
azithromycin alone provides coverage against most commonly
isolated bite-wound pathogens. As MRSA becomes more common in the community and evidence of its transmission between
humans and their animal contacts increases, empirical use of
agents active against MRSA should be considered in high-risk
situations while culture results are awaited.
Antibiotics are generally given for 10–14 days, but the
response to therapy must be carefully monitored. Failure to
respond should prompt a consideration of diagnostic alternatives and surgical evaluation for possible drainage or debridement. Complications such as osteomyelitis or septic arthritis
mandate a longer duration of therapy.
Management of C. canimorsus sepsis requires a 2-week course
of IV penicillin G (2 million units IV every 4 h) and supportive
measures. Alternative agents for the treatment of C. canimorsus
infection include cephalosporins and fluoroquinolones. Serious
infection with P. multocida (e.g., pneumonia, sepsis, or meningitis) should also be treated with IV penicillin G. Alternative
agents include second- or third-generation cephalosporins or
ciprofloxacin.
Bites by venomous snakes (Chap. 396) may not require antibiotic treatment. Because it is often difficult to distinguish signs
of infection from tissue damage caused by the envenomation,
many authorities continue to recommend treatment directed
against the snake’s oral flora—i.e., the administration of broadly
active agents such as ceftriaxone (1–2 g IV every 12–24 h)
or ampicillin/sulbactam (1.5–3.0 g IV every 6 h).
Seal finger appears to respond to doxycycline (100 mg twice
daily for a duration guided by the response to therapy).
Infectious Diseases
Presumptive or Prophylactic Therapy The use of antibiotics for
patients presenting early (within 8 h) after bite injury is controversial. Although symptomatic infection frequently will not yet
have manifested at this point, many early wounds will harbor
pathogens, and many will become infected. Studies of antibiotic
prophylaxis for wound infections are limited and have often
included only small numbers of cases in which various types
of wounds have been managed according to various protocols.
A meta-analysis of eight randomized trials of prophylactic
antibiotics in patients with dog-bite wounds demonstrated a
reduction in the rate of infection by 50% with prophylaxis.
However, in the absence of sound clinical trials, many clinicians
base the decision to treat bite wounds with empirical antibiotics
on the species of the biting animal; the location, severity, and
extent of the bite wound; and the existence of comorbid conditions in the host. All human- and monkey-bite wounds should
be treated presumptively because of the high rate of infection.
Most cat-bite wounds, particularly those involving the hand,
should be treated. Other factors favoring treatment for bite
wounds include severe injury, as in crush wounds; potential
bone or joint involvement; involvement of the hands or genital
region; host immunocompromise, including that due to liver
disease or splenectomy; and prior mastectomy on the side of
an involved upper extremity. When prophylactic antibiotics are
administered, they are usually given for 3–5 days.
Rabies and Tetanus Prophylaxis Rabies prophylaxis, consisting
of both passive administration of rabies immune globulin (with
as much of the dose as possible infiltrated into and around the
wound) and active immunization with rabies vaccine, should
24-4
be given in consultation with local and regional public health
authorities for many wild-animal (and some domestic-animal)
bites and scratches as well as for certain nonbite exposures
(Chap. 195). Rabies is endemic in a variety of animals, including dogs and cats in many areas of the world. Many local health
authorities require the reporting of all animal bites. A tetanus
booster immunization should be given if the patient has undergone primary immunization but has not received a booster dose
in the past 5 years. Patients who have not previously completed
primary immunization should be immunized and should also
receive tetanus immune globulin. Elevation of the site of injury is
an important adjunct to antimicrobial therapy. Immobilization
of the infected area, especially the hand, is also beneficial.
FURTHER READINGS
Baker AS et al: Isolation of Mycoplasma species from a patient with
seal finger. Clin Infect Dis 27:1168, 1998
Brook I: Management of human and animal bite wounds: An
overview. Adv Skin Wound Care 18:197, 2005
Centers for Disease Control and Prevention: Nonfatal dog
bite–related injuries treated in hospital emergency departments—
United States, 2001. MMWR Morb Mortal Wkly Rep 52:605,
2003
Cummings P: Antibiotics to prevent infection in patients with dog
bite wounds: A meta-analysis of randomized trials. Ann Emerg
Med 23:535, 1994
Fallouji MA: Traumatic love bites. Br J Surg 77:100, 1990
Fleisher GR: The management of bite wounds. N Engl J Med
340:138, 1999
Goldstein EJ: Bite wounds and infection. Clin Infect Dis 14:633,
1992
Kaiser RM et al: Clinical significance and epidemiology of NO-1,
an unusual bacterium associated with dog and cat bites. Emerg
Infect Dis 8:171, 2002
Kullberg BJ et al: Purpura fulminans and symmetrical peripheral
gangrene caused by Capnocytophaga canimorsus (formerly DF-2)
septicemia—a complication of dog bite. Medicine (Baltimore)
70:287, 1991
Oehler RL et al: Bite-related and septic syndromes caused by cats
and dogs. Lancet Infect Dis 9:439, 2009
Rankin S et al: Panton Valentine leukocidin (PVL) toxin positive
MRSA strains isolated from companion animals. Vet Microbiol
108: 145, 2005
Talan DA et al: Bacteriological analysis of infected dog and cat
bites. N Engl J Med 340:85, 1999
Tan JS: Human zoonotic infections transmitted by dogs and cats.
Arch Intern Med 157:1933, 1977
Weber DJ et al: Infections resulting from animal bites. Infect Dis
Clin North Am 5:663, 1991
Weinberg AN, Branda JA: Case 31-2010. A 29-year-old woman
with fever after a cat bite. N Engl J Med 363:1560, 2010
Weiss HB et al: Incidence of dog bite injuries treated in emergency
departments. JAMA 279:51, 1998
Copyright © 2012 The McGraw-Hill Companies, Inc. All rights reserved.